On June 23, 84-year old Galbraith was found dead in her room at The Commons at Brightmore, a Wilmington adult home facility.

In response, the N.C. Division of Health Service Regulation responded with an investigation into the center. Rhine says the report’s findings were shocking.

“I’ve been practicing since 1998 and I have never seen a report like that which was issued by the state and the county,” he says.

It lists pages of deficiencies, many of those referring to “resident # 1,” who’s body was found with her head caught between the hospital bed and the side rail.

Rhine says it took staff three hours to discover Galbraith.

“At 10:30 is when the last check occurred and I don’t believe that she was seen until about 1:30 in the morning,” Rhine says.

Galbraith’s bed had railings that were not ordered for The Commons to provide.

“Those railings should never be used unless a doctor orders that they are appropriate to use those, so this was the responsibility of The Commons,” says Wanda Marino, New Hanover County DSS assistant director.

The state cited the center with an A1 violation, which is the most severe penalty given. The violation is defined as resulting “in death or serious harm or results in substantial risk that death or serious harm will occur.” The center was given until July 29 to correct the violations.

Rhine says what is most upsetting to the family is how the incident was dealt with.

“The Galbraiths weren’t called by the facility at all,” he says. “They were told of this death by the police and that occurred the next morning.”

New Hanover County DSS also investigated Galbraith’s death and immediately put a plan in place to ensure the safety of other residents at The Commons. Marino says the center has been complying since the plan was implemented.

An attorney for the center e-mailed a statement in response to the investigation:

“We at The Commons are deeply saddened by the passing of Nannette Galbraith, a long-time resident of our assisted living community,” it reads. “We extend our deepest sympathies to Ms. Galbraith’s family and loved ones.

“We are not able to comment specifically on Ms. Galbraith’s passing at this time in accordance with patient confidentiality requirements, however, The Commons is working closely with representatives of the North Carolina Department of Health and Human Services to address any areas of concern.
The Commons implemented all components of a Plan of Correction in response to the survey findings by the North Carolina Division of Health Service Regulation (“DHSR”) while the survey team was still in the building. A formal Plan of Correction shall be submitted to DHSR this week.”